Subcontractor’s
Lien and Bond Claim
Date

Randall S. Blankenhorn

Secretary

Department of Transportation

2300 South Dirksen Parkway, Room 300

Springfield, IL 62764

NOTICE OF LIEN AND BOND CLAIM

770 ILCS 60/23(c)

and 30 ILCS 550/1 & 550/2

YOU ARE HEREBY NOTIFIED that
was employed by
to provide construction supplies/services at the location of
under Contract # / ; / by reason thereof there is due the undersigned sum of
Dollars
($). / The undersigned claims a lien on the money, bonds or warrants due or to
become due from the Illinois Department of Transportation for the amount of its claim aforesaid,
according to Statutes in such case made and provided and claims recovery under the contractor’s bond.
Company:
Address:
Telephone:
Email:
By:
(Name and Title)
STATE OF ILLINOIS
COUNTY OF
Subscribed and sworn to before me this / day of / , / .
Notary Public

cc: Prime Contractor

Bonding Company

CERTIFIED MAIL - RETURN RECEIPT REQUESTED TO ADDRESSEE ONLY

Printed 5/28/2015 OCC 2401 (Rev. 05/28/15)